More than a thousand asylum seekers have died trying to get to Australia by boat. But how many of them could have been saved? Australia’s search and rescue authorities stand accused of unnecessary delays, disregarding distress calls and passing responsibility to Indonesia, which is not equipped to carry out rescue operations. Jess Hill investigates.

Since 2001, almost 1400 asylum seekers have drowned between Indonesia and Australia. More than 300 have drowned in the past 12 months alone. Why are so many asylum seekers drowning on their way to Australia, and could we have done more to save them?

Background Briefing has looked at the circumstances surrounding the sinking of four boats over the past two years, in which more than 400 asylum seekers drowned. What has emerged is a disturbing pattern of delays, cover-ups and communication breakdowns.

In June 2012, a 20-metre fishing boat codenamed the SIEV 358 sank halfway between Indonesia and Christmas Island. The boat was grossly overcrowded with more than 200 men and boys; mostly Pakistanis and Afghans fleeing the Taliban and Al Qaeda. Its passengers had made 16 calls for help to Australia's maritime safety authority over two days. Increasingly distressed callers said the boat was broken on one side and taking on water, and begged to be rescued.

At first I couldn't believe that our boat has sank, but I saw a toy is coming from the inside of the boat; it is coming by water. When it comes close to me, I realised that no, that was not a toy. That was a kid.

Esmat Adine, Hazara asylum seeker

But no help came. The boat was in Indonesia's search and rescue zone, which covers most of the ocean between Indonesia and Christmas Island, so Australia's maritime safety authority transferred responsibility to its Indonesian counterpart, BASARNAS.

Thirty-two hours after the first distress call was made, the man who made it—and 101 others—were dead.

Lawyer George Newhouse, who has worked on three coronial inquests into the sinking of asylum boats, says delegating to BASARNAS is unacceptable.

'How can a safety authority in good conscience hand over responsibility for saving people's lives to an organisation that they know is not capable of fulfilling that role?' he says.

Indonesia's BASARNAS office in West Java, which responds to boats in distress on the coastline commonly used by people smugglers, is hopelessly ill-equipped to conduct open sea rescues. The head of operations there, Rochmali, says all they have at their disposal are rubber boats and traditional fishing vessels, which can't go more than five nautical miles from shore.

This article represents part of a largerBackground Briefinginvestigation. Listen toJess Hill's full report on Sunday at 8.05 am or use the podcast links above after broadcast.

Former diplomat Tony Kevin, who has been an outspoken critic of Australia's search and rescue authorities since 353 people drowned on the boat known as SIEVX, is more direct in his condemnation of Australia's maritime safety authority.

'What concerns me greatly now is the evidence of a systemic doctrine, particularly inside the Australian Maritime Safety Authority (AMSA)—what you might call a systemic culture of scepticism of asylum seeker distress claims. A spirit of "We better wait and see what happens to this, if they're really in distress, because we know very often that they're not".'

AMSA strongly rejects this assertion from Tony Kevin. However, the question of when a call is deemed to be a genuine distress call was at the heart of a recent coronial inquest into the asylum seekers who died on the SIEV 358.

But these weren't the only asylum deaths at sea Australia could have prevented.

In the dead of night on 17 December 2011, an asylum seeker boat called the Barokah left the coast of Java with around 250 men, women and children on board. One of them was ethnic Hazara man, Esmat Adine. The boat was so crowded, Adine couldn't even find a place to sit. The Barokah was just 40 nautical miles from Indonesia when it fell apart.

'At first I couldn't believe that our boat has sank,' Adine recalls. 'But I saw a toy is coming from the inside of the boat; it is coming by water. When it comes close to me, I realised that no, that was not a toy. That was a kid. That was a kid named Daniel. Daniel was with his mother; they were sitting in front of me, next to me, while we came by bus. When I saw Daniel's body, I realised that our boat has sank, and there is no further hope for us to be alive. '

Eight hours later, at 3 o'clock that afternoon, a passing fishing boat found around a hundred people in high seas, desperately clinging to debris. It was only able to rescue 34 people. Adine shouted to the people in the water, 'Be patient—we will bring you more boats, and they will rescue you.'

In Canberra that evening, Australian agencies became aware the Barokah had sunk. They told Indonesian authorities, because the boat was in their search and rescue zone.

Months later, customs officials would tell a Senate Estimates hearing that Indonesia had initially declined Australia's offer to help with the search and rescue.

But the official incident timeline, which Fairfax obtained under freedom information laws, revealed that BASARNAS, Indonesia's search and rescue agency, had asked AMSA to coordinate the rescue response—AMSA refused.

For two days, while men, women and children struggled to survive in waves up to six metres high, Indonesia and Australia did nothing.

Finally, on December 19, BASARNAS asked again for help. This time, AMSA agreed, and dispatched naval and Customs assets to the scene.

But it was too late. Two hundred and one people were dead.

In April this year, asylum seekers were again left to drown as AMSA and BASARNAS failed to collaborate efficiently. Reporting from Indonesia, ABC correspondent George Roberts said, 'All we've been able to find out so far—unless things have changed since late last night—AMSA wasn't helping yet or Australian authorities weren't helping yet and Indonesia hadn't launched its own search.'

'So, it seems to be the same kind of stand-off we had last year where Australia knew there was a problem, Indonesia was incapable of being able to help and as a result people are left in the water for hours on end.'

Fifty-eight people are still missing.

In June this year, another boat sank, this time within easy reach of Australian patrol boats. A Customs plane sighted it 28 nautical miles from the island—just four miles outside its interception zone. Approximately 55 men, women, and children were seen on deck, waving at the plane.

After the event, the government claimed the boat had shown no visual signs of distress. But official documents from AMSA's Rescue Coordination Centre (RCC), which Fairfax again obtained under freedom of information laws, showed that Customs had reported the boat as being 'dead in the water', and had been concerned about the boat from the moment they sighted it.

As the hours dragged on, the admiral in charge of Border Protection Command became increasingly concerned for the boat's safety, and asked the RCC to initiate a search. But AMSA refused, saying they were still assessing the evidence. When debris is sighted, AMSA said, the surveillance would then move to a SAR phase.

Two days later, the boat was found, capsized. Thirteen bodies were found. There were no survivors.

Listen to Jess Hill's full report this Sunday, when Background Briefing will be taking a forensic look behind the scenes at AMSA and asking: were the deaths of more than 400 people easily preventable?

Transcript

Jess Hill: On the 19th of June last year, a desperate call for help was made from a small wooden fishing boat bound for Christmas Island.

Caller: Please, please help me.

Dan: Okay.

Caller: Please help me...200, 200 person with me. Ship is very heavy.

Dan: Okay. Did you say there's 200 on the boat?

Caller: Yeah, yeah, that's it.

Jess Hill: The boat was grossly overcrowded with more than 200 men and boys, mostly Pakistanis and Afghans fleeing the Taliban and Al Qaeda.

Ahmed: [translated] For most of us, it was our very first time on a boat in an open sea with no sight of land. Obviously it was very scary, and calling Australian authorities and seeking their help was the only thing we thought could save our lives.

Jess Hill: Over two days, they made 16 calls for help to Australian authorities. The boat was in Indonesia's search and rescue zone, so Australia's maritime safety authority transferred responsibility to its Indonesian counterpart, BASARNAS. But 32 hours after the first call was made, the man who made it—and 101 others—were dead.

George Newhouse: How can a safety authority in good conscience hand over responsibility for people's lives - for saving people's lives - to an organisation that they know is not capable of fulfilling that role?

Jess Hill: This question has been at the heart of a recent coronial inquest into the sinking of this boat, the SIEV 358, also codenamed the Kaniva.

Marco Tedeschi: I mean, I think they knew that BASARNAS can't effectively respond once the boat is sort of 30, 40 nautical miles off the coast of Indonesia. That's the reality, and we know that.

Jess Hill: In fact, off the coast of Java, from where the majority of asylum boats leave, BASARNAS, Indonesia's search and rescue agency, has a search and rescue range much shorter than that.

Rochmali: [translated] We can't rescue people too far out to sea. We can only go one to five nautical miles from shore. After that we can't do anything.

Jess Hill: Since 2001, almost 1,400 asylum seekers have drowned between Indonesia and Australia. More than 300 have drowned in the past 12 months alone. Why have so many asylum seekers drowned on their way to Australia, and could we have done more to save them?

Hello, and welcome to Background Briefing, I'm Jess Hill.

In the past few years, hundreds of unseaworthy boats have made the treacherous journey from Indonesia to Christmas Island.

When these boats run into trouble at sea, it's now common practice for asylum seekers to call Australia for help. But while Christmas Island is Australian territory, the stretch of ocean between there and Indonesia is almost entirely within Indonesia's search and rescue zone.

According to former Australian ambassador Tony Kevin, Indonesia has neither the resources nor the inclination to rescue asylum seekers at sea.

Tony Kevin: There is a lack of resources, there is a lack of bureaucratic coordination, there is even a lack of will on the part of Indonesian agencies to do anything about these boats that have left Indonesia permanently, they're not coming back. Basically Indonesia washes its hands of these boats the minute they leave port.

Jess Hill: But he reserves his strongest criticism for Australia's maritime search and rescue authority, AMSA. Tony Kevin has been an outspoken critic of Australian search and rescue authorities since 2001, when 353 asylum seekers drowned on a boat known as SIEV X.

Tony Kevin: We don't seem to be able to engage in a sustained, morally based critique of why 1,000 people have died at sea, and Australia's approaches over the last four years. I mean, that is a shocking statistic. It's shocking in the sense that many of these deaths were avoidable.

Jess Hill: Were they avoidable? Background Briefing has looked at the circumstances around four sinkings over the past two years, in which more than 400 asylum seekers drowned. What emerges is a disturbing pattern of delays, cover-ups and communication breakdowns, and questions about the adequacy of Australia's response.

The people who drowned on the SIEV 358, which sank in June 2012, weren't the only deaths that Australia could have prevented. In December 2011, an asylum seeker boat called the Barokah left the coast of Java with 250 people on board. One of them was Esmat Adine.

Esmat Adine: I couldn't even find a place to sit, I just sit in the aisle in front of the window.

Jess Hill: Esmat Adine fled Afghanistan after his work for Australian and American aid agencies made him a target for the Taliban. After arriving in Indonesia, he went to the Australian embassy to request asylum, but officials said there was nothing they could do.

So in the dead of night on December 17, 2011, Esmat Adine got on a boat. Just a few hours out of port, when it was around 40 nautical miles off the cost of Java, the boat ran into trouble.

Esmat Adine: I was just lying, I was sick, and the water touched my feet. When I opened my eyes I saw that the boat was capsized. At first I couldn't believe that our boat has sank. But I saw a toy is coming from the inside of the boat; it is coming by water. When it comes close to me, I realise that no, that was not a toy, that was a kid. That was a kid named Daniel. Daniel was with his mother, they were sitting in front of me. And after that, when I saw Daniel's body, I realised that yeah, our boat has sank, and there is no hope for us to be alive.

Jess Hill: That afternoon, a passing fishing boat found around 100 people desperately clinging to debris.

Esmat Adine: They were alive, most of them were alive. About 100 people were alive.

Jess Hill: The small fishing boat was only able to rescue 34 people. Esmat Adine was one of them. He tried to reassure those still in the water.

Esmat Adine: I shouted on them that, 'Be patient, we go now, we will bring you more boats, and they will rescue you.'

Jess Hill: That evening, Australian agencies became aware the Barokah had sunk. They notified Indonesian authorities, because the boat was in their search and rescue zone. Months later, customs officials would tell a Senate Estimates hearing that Indonesia had initially declined Australia's offer to help with the search and rescue.

But documents subsequently obtained by The Sun-Herald under freedom of information laws show that just a few hours after they learned of the sinking, BASARNAS, Indonesia's search and rescue agency, asked AMSA to coordinate the rescue response. But AMSA refused, stating that the boat was in Indonesia's search and rescue zone.

For two days, while men, women and children struggled to survive in waves up to six metres high, Indonesia and Australia did nothing. Finally, BASARNAS asked again for help. This time, AMSA agreed.

Jason Clare, the Minister for Home Affairs, went on ABC News Breakfast to talk up the government's response.

Jason Clare [archival]: We made the offer yesterday of a P3 surveillance aircraft, as well as an Armidale-class patrol boat. The Indonesians have accepted that offer. And so this morning, that patrol boat and surveillance aircraft will head into the search and rescue region.

Channel 10 News [archival]: Wild weather is hampering the frantic rescue mission for an asylum boat which sunk overnight off the Indonesian coast. Around 250 people were on board, bound for Australia.

Jess Hill: A passing coal carrier picked up another 13 people, but by the time Australian authorities reached the scene, they found no more survivors. A total of 201 people were dead.

Survivor Esmat Adine says the response from both countries was inhumane.

Esmat Adine: People are being killed, and here, two governments they compete with each other. They don't even think that their peoples are dying in the water.

Jess Hill: Six months later, AMSA handed responsibility for another asylum boat in distress to the hopelessly ill-equipped BASARNAS. This was the SIEV 358, on which 102 people drowned. As we'll hear, their deaths have been the subject of an extensive coronial inquiry.

Following this tragic incident, the Australian government made commitments to improve search and rescue coordination between the two countries. Then in April this year, asylum seekers were again left to drown as AMSA and BASARNAS failed to collaborate efficiently.

The ABC's Indonesia correspondent George Roberts explained.

George Roberts [archival]: There are various reports coming through that about 60 people are missing and that there might have been as many as 72 people on board that boat, or perhaps more, and that 14 people were plucked from the sea by fishermen.

All we've been able to find out so far, unless things have changed since late last night, AMSA wasn't helping yet or Australian authorities weren't helping yet and Indonesian hadn't launched its own search.

So, it seems to be the same kind of stand-off we had last year where Australia knew there was a problem, Indonesia was incapable of being able to help and as a result people are left in the water for hours on end.

Jess Hill: Fifty-eight people are still missing.

Then in June this year, another boat sank, this time within easy reach of Australian patrol boats. A Customs plane sighted it 28 nautical miles from Christmas Island, just four miles outside its interception zone. Approximately 55 men, women and children were seen on deck, waving at the plane.

After the event, the government claimed the boat had shown no visual signs of distress. But official documents from AMSA's Rescue Coordination Centre, released to Fairfax under freedom of information laws, showed that Customs had reported the boat as being 'dead in the water', and they had been concerned about the boat from the moment they sighted it.

Without engine power, these rickety boats commonly capsize. The official incident timeline reveals that when the boat failed to arrive at Christmas Island, the admiral in charge of Defence and Border Protection Command asked the Rescue Coordination Centre to initiate a search.

Tony Kevin: He was asking AMSA to issue a distress alert, a Pan Pan, which is one stage below a mayday. AMSA declined to do so, they said we're continuing to assess the evidence.

Jess Hill: 'If debris is sighted,' AMSA said, 'the surveillance would then move to a search and rescue phase.'

Tony Kevin: That boat subsequently disappeared. We didn't send out an interception vessel for eight hours, by which time it was after dark. We found the capsized hull floating underwater, 60 miles to the west two days later.

Jess Hill: There were no survivors. Thirteen bodies were found in the water but, controversially, Customs and Border Protection didn't retrieve them, citing other operational priorities.

Tony Kevin: We never recovered any bodies, and therefore there may never be a legal basis for a coronial inquest. What concerns me greatly now is what you might call a systemic culture of scepticism of asylum seeker distress claims, a spirit of 'we'd better wait and see what happens to this, if they're really in distress, because we know very often they're not.'

Jess Hill: AMSA strongly rejects this. However, the question of when a call for help is deemed to be a genuine distress call was at the heart of a recent colonial inquest. The inquest was into the sinking of the boat known as SIEV 358.

On June 19 last year, the SIEV 358 left the coast of Java, bound for Christmas Island. On the boat that night was 31-year old Hazara man Ahmed, who'd travelled to Indonesia from the portside city of Karachi, in Pakistan. An electric welder by trade, Ahmed had also been a volunteer social worker and a security guard at his local mosque.

Background Briefing can't use Ahmed's real name because survivors from the SIEV 358 have had their names suppressed by the coroner.

Extremist Sunni groups have openly vowed to eliminate Hazaras in Afghanistan and Pakistan. When two of Ahmed's relatives were shot, he decided to seek asylum in Australia, because it was the only country he knew of that was accepting refugees. He knew how dangerous the boat journey could be.

Ahmed: [translated] Obviously I was afraid of the boat. I had heard that many people had drowned in the sea since 2000 and that they were never found. But I had no choice but to take the boat. I couldn't see any other option.

Jess Hill: On the night of June 18, he and hundreds of other asylum seekers were driven to a beach in Java. They were told that two small boats would take them out to a big boat, anchored several kilometres offshore, which would then take them to Christmas Island.

Ahmed: [translated] Two small boats were used to transport us to the big boat. By the time we got to the beach, one boat had already gone, so we were in the second boat. When we reached the big boat, there were people already on the boat screaming and yelling us, 'Don't board this boat! It's already full!'

Jess Hill: Did you have an option to go back to the shore? Did you want to go back to the shore?

Ahmed: [translated] It was a chaotic situation, because on one side we had people on the boat screaming at us not to board, and on the other side the Indonesians were pushing us to, 'Come on, get in, hurry up, the police are going to come, come on, we have to go!'

Jess Hill: There were only enough lifejackets for around half the people on board. Ahmed managed to get his hands on one, and squeezed into a tiny spot on the deck next to some other Hazaras. The deck was so crowded, Ahmed couldn't even get up to go to the toilet.

People sitting below deck said they had to be careful where they put their feet, for fear of falling through the floor. Several hours into the journey, the SIEV 358 ran aground on a sandbank. When some Indonesian fishing boats stopped to help dislodge it, one of the crewmembers said he said he didn't think it was going to make it to Christmas Island, and hitched a ride back to the mainland.

That night, the sea turned violent.

Ahmed: [translated] That night, when rough waves began hitting the boat, I started thinking that it was really going to be very hard for us to reach Australia. As the conditions got worse, I became more and more afraid.

Jess Hill: As the boat lurched over four-metre waves, passengers had to bang pieces of timber back into place. Ahmed hung on desperately, convinced the boat was about to capsize. That night, at 7.52 pm, AMSA's Rescue Coordination Centre in Canberra received the first call from the boat.

Dan: Okay. Yes, sir, I'm trying to help, but I need to know where you are.

Jess Hill: The noise from the wind and the engine made the caller's broken English virtually impossible to understand.

Dan: I can't understand. Do you speak Indonesian or Arabic? What language do you speak?

Caller: Okay. No problem. Arabic, yeah, I know Arabic.

Dan: Okay. Okay. You wait. You wait. I'll get, I'll get an Arabic speaker. Okay. I'm going to put…I'm going to put you on hold. Do not hang up.

Jess Hill: Dan, the officer on shift that night, needed the caller to give him a clear GPS reading, so he put him on hold and dialled a translation service.

Automated message: Thank you for calling the Translating and Interpreting Service, TIS National. An operator will be with you shortly.

All our operators are busy at the moment.

Dan: Oh no…

Automated message: You have been placed in a queue. Please stand by…

Dan: Are you able to pick him up from that end and just keep him on the line?

[Audio: Hold music]

Tania: TIS National, this is Tania. How can I help?

Dan: G'day. My name's Dan. I'm calling from Rescue Coordination Centre in Canberra. One of my colleagues spoke to you earlier about arranging an Arabic speaker?

Tania: Yes.

Dan: Yeah, we've got, we've got the person on the line. Are you able to get him on?

Tania: Yep, no worries. Have you got your client code at all for the..?

Dan: Have you got the client code at all?

Jess Hill: Dan hurriedly read out the code, and an incident number.

Tania: Okay, no worries, hold the line now, I'll call through to an interpreter for you, Dan.

Dan: Thank you.

[Audio: Hold music]

Dan: Come on.

Jess Hill: By the time the interpreter answered, the call from the boat had dropped out. It took three-and-a-half hours of broken exchanges for Dan to get a GPS reading from the boat. The coordinates revealed that the SIEV 358 was 38 nautical miles south of Indonesia.

Caller: Hello?

Dan: Sir, your…your boat, if it's broken, you need to turn back to Indonesia. You are still inside Indonesian waters. If your boat is broken, Christmas Island is a long way away. You need to go back to Indonesia.

Caller: Okay, okay, okay.

Dan: Okay, if you…are you there? Well, I sorted that out. [laughs]

Jess Hill: That's where the recording ends. The RCC contacted BASARNAS, and asked them to coordinate the search and rescue response. The communication problem was obvious.

Jess Hill: Under an agreement between Australian and Indonesia, whoever receives the first distress call is obliged to respond to it, no matter where the vessel is, until the relevant agency is able to take over. But after finding out where the boat was, all AMSA did for the next 7.5 hours was press BASARNAS to take responsibility for it.

At the coronial inquest into the sinking, AMSA's director Alan Lloyd said they didn't launch a rescue response because the calls from the boat were not thought to be genuine distress calls.

Background Briefing has dramatised the exchange between Alan Lloyd and the Counsel assisting the Coroner, Marco Tedeschi. It begins with Alan Lloyd.

Alan Lloyd: RCC Australia was seeking information about the position of the boat. During the several phone calls, received information including the following: the vessel was in international waters, there were 204 male persons on board, no life jackets on board, no EPIRB, no water. The boat was old and had a lot of water. Request help, 'please help me', and that the vessel was from Indonesia.

Marco Tedeschi: Now, can I stop you there? Would that amount to a distress call or an alert call?

Alan Lloyd: In the context of the phone calls, it's what I would call the normal refugee patter. It normally takes us a number of hours to establish basic information. In fact, it can take a long time to get that basic positional 'who are you' type of information, and, of course, we listen to the context or the tone of the call. If someone's screaming down the phone at us…you know, a mayday call is quite distinct, or a distress call...

Marco Tedeschi: Yes?

Alan Lloyd: ...as opposed to the provision of information. So information wise, yes, it was looking for some form of assistance. I don't classify it as a distress call.

Jess Hill: Alan Lloyd's reference to 'refugee patter' surprised many in the courtroom that day, including Tony Kevin.

Tony Kevin: The statement by the AMSA chief witness that distress calls were interpreted as the normal refugee patter, that certainly sent a shiver through the whole courtroom, and the insensitivity and callousness of that statement was breathtaking. Apparently if you're an asylum seeker you're supposed to be jabbering hysterically, otherwise your call of distress will not be taken seriously.

Alan Lloyd: The RCC received more calls from the boat at about 11.06 pm, 11.26 and 11.28 pm. The caller advised that the boat was broken on one side.

Marco Tedeschi: Can I just stop you there for a moment? Would the information that the boat was broken on one side raise concern with the Rescue Coordination Centre people taking that call?

Alan Lloyd: It was information, yes, it would be considered.

Marco Tedeschi: But would…would that be something that you wouldn't categorise as refugee patter?

Alan Lloyd: Unfortunately I would classify it as that.

Marco Tedeschi: You would classify it as refugee patter?

Alan Lloyd: Yes.

Jess Hill: The West Australian coroner, Alastair Hope, interrupted.

Alastair Hope: Well, if true, it indicated there was a possible emergency?

Alan Lloyd: Yes, Your Honour, that there was a chance. I note from the transaction it was actually the word 'little broken', as opposed to 'broken', in the RCC's records.

Jess Hill: Alan Lloyd told the court asylum seekers routinely make 'hoax' calls to the Rescue Coordination Centre, and that they generally follow a script. When he was asked to explain what would constitute a genuine distress call, he refused to say, because that was 'classified information' that would 'give away how people smugglers can manipulate the system'.

Background Briefing wrote to AMSA requesting an interview several weeks ago. At the time that request was refused. They said that as the government was operating under caretaker conventions they would be unable to participate. But at the last minute, after they learned of specific allegations being made in this program, AMSA themselves requested an interview. Unfortunately we were unable to speak to anyone from the authority's emergency response division. Mal Larsen is AMSA's general manager of corporate relations.

Mal Larsen: A key issue is to try to identify the precise problem. For instance, is it taking on water, are the engines broken, and the location of the vessel. So that's the key work we go through in the early phases when you talk about assessing a distress situation. It's finding basic information about where the vessel is.

Jess Hill: That did happen in the SIEV 358, there was 16 distress calls, there was indications that the boat was broken on one side, the boat was taking on water, it was low in the water, and that people were afraid that it would imminently capsize. That call was still judged, according to Alan Lloyd, to be a hoax.

Mal Larsen: No, that's not true, I reject that. We never thought that was a hoax.

Jess Hill: He said it was not deemed to be a genuine distress call.

Mal Larsen: The vessel was 40 miles from Indonesia, we worked with BASARNAS and they accepted coordination…

Jess Hill: But Mal Larsen, okay, clear this up for me, because Alan Lloyd made a very significant point that that boat had been assessed as not being in distress. He made reference to hoax calls that the Rescue Coordination Centre receives from refugee vessels, and then said that the calls that they had received from the SIEV 358 could be described as refugee patter.

Mal Larsen: The reality is that many calls from these vessels are giving us information which are designed to facilitate a rescue by an Australian vessel. We understand that, that's what they are trying to do, they're trying to get picked up by an Australian authority. Our job as a search and rescue agency is to try to ensure that people who are in distress get rescued.

Barry Learoyd: In my experience, any vessel that puts a radio call out that says that vessel's in distress, a mayday, and you are in a position to respond to that, then you are bound by maritime law and indeed by just your own values to do so.

You've got to react to what you hear, and then make a decision once you're on the scene. You can't say, oh, that might just be a hoax call and disregard it. Someone on the water—a fellow mariner, whether that person is an asylum seeker or not—is in distress, and you are duty bound, if you're able to, to go and provide support to that vessel.

Jess Hill: The first call for help from SIEV 358 was made to AMSA on the night of June 19. Eleven hours later, at seven o'clock the next morning, Indonesia accepted coordination of the incident.

Marco Tedeschi said the hours wasted that night were critical. He spoke to Background Briefing via studio link from Perth.

Marco Tedeschi: They did a terrific job in the first 3.5 hours in locating the position of the SIEV 358, they did that really well. But they spent the next 7.5 hours trying to transfer the responsibility to Indonesia, instead of just issuing an emergency broadcast to merchant vessels. And the evidence of Mr Lloyd was that within one and eight hours, that merchant vessels would have been able to respond. So they would have been able to get to SIEV 358 well before it sank.

Under the search and rescue agreement between Australia and Indonesia, one of the things that's meant to be considered is who has the greater capability to undertake the search and rescue. So when the transfer of the responsibility took place, they considered the fact that the boat was closer to Indonesia at that stage. Fair enough, but they didn't consider who had the greater capability to respond. And that's one of the factors that should have been considered.

The BASARNAS office in West Java is located on the coastline most commonly used by people smugglers. Background Briefing's Asia reporter, Rebecca Henschke, spoke to Rochmali, the head of operations.

Rochmali: [translated] We have to use traditional fishing boats. If the waves are big and the rescue is close to the sea we use rubber boats.

Rebecca Henschke: [translated] Is your BASARNAS office capable of conducting rescue operations in the open sea?

Rochmali: [translated] These are traditional fishing boats, so they have small machines and we use paddles. We can't rescue people too far out to sea. We can only go one to five nautical miles from shore. After that we can't do anything.

Jess Hill: People on the boat continued to call AMSA, begging to be rescued.

Ahmed: [Translated] Every time a call was being made to the Australian authorities, everyone would think and would hope that the Australian authorities would say okay, we are now coming to rescue you. But the moment we would hear that we are still in Indonesian waters and they can't come, we would go back to feeling hopeless and scared.

Jess Hill: The fate of the SIEV 358 was now in Indonesia's hands. Marco Tedeschi:

Marco Tedeschi: It was very hard to work out what they did, but it was some kind of radio broadcast that they gave from different places in Indonesia. That was all they did. They didn't deploy a search and rescue vessel. And by the time SIEV 358 was 40 nautical miles or somewhere of that order off the coast of Indonesia, they weren't able to do it anyway.

Jess Hill: At 3.15 that afternoon, an Australian Customs plane conducting routine surveillance spotted the SIEV 358. It told the RCC the vessel was low in the water, but there were no visual sign of distress. Footage taken by the plane was shown to the court. Marco Tedeschi:

Marco Tedeschi: The boat did seem to be travelling under its own power, slowly, but in large seas. And that surveillance was taken from a distance of some kilometres away, covertly by a Dash-8. So the people on the boat wouldn't have known that an Australian aircraft had done some surveillance of them.

Jess Hill: As the Customs plane covertly observed the SIEV 358 that afternoon, the People Smuggling Intelligence Analysis Group met in Canberra. The director of AMSA, Alan Lloyd, and representatives from Customs, Defence and other federal government agencies collectively assessed that the boat was not in distress.

According to official transcripts, what you're about to hear is the last call the SIEV 358 made to the Rescue Coordination Centre.

Caller: Sir, we want rescue fast. Can you please [unclear]…

Mike: Yes, I heard that, sir. I heard you want rescue, but I need to talk to you about what is occurring, what is wrong on board.

Caller: Are we in Australian water now?

Mike: No, no, negative, not in Australia, no, not in Australian waters. You are still in Indonesian waters. You need to come further south. You have some way to go, sir. [beeps] He's gone.

Jess Hill: At around 5 o'clock the next morning, a young Indonesian crewmember operating the bilge pump fell asleep. The engine flooded with water. One of the passengers cried out, 'Wake up!' Within seconds, the boat capsized.

Ahmed: [translated] The moment when I fell off the boat into the water, my mind stopped thinking. All I could see around me was chaos. People were trying to get on to the debris of the boat, and there were people trying to grab hold of each other, trying to save themselves at the cost of others' deaths.

Jess Hill: When the boat flipped over, dozens of people sitting below deck were trapped. As the people struggling in the water fought to grab hold of the upturned hull, an Indonesian crewmember tied one end of a rope to the boat's propeller shaft and the other around his waist, and jumped into the water to pull people back to the boat. But Ahmed moved away from the boat, hoping his lifejacket would keep him afloat.

Ahmed: [translated] After a few minutes when I became more conscious of what was happening, I thought why am I going away from the boat, I should be nearby the boat if I want to save my life. But when I looked around, there was no boat. The boat was no longer there.

Jess Hill: Powerful currents swept some survivors more than three nautical miles away from the boat.

Ahmed: [translated] In the early morning, I could see the bodies floating on the water. I had to hang on to the bodies, because I was exhausted. After four or five hours, my lifejacket had torn apart. Some other people helped me to get another lifejacket from a dead body that was floating on the water. I approached the dead body and I took the lifejacket off the body.

Jess Hill: A Customs plane flying over the area sighted them at one o'clock that afternoon. Half-an-hour later, RCC Australia issued an emergency broadcast to ships in the area and dispatched two Australian naval boats to the scene.

The container ship the MV Dragon arrived on the scene 90 minutes later. Heavy swell slammed the upturned hull violently against the ship, but its crew still managed to rescue eight people who were clinging to it. Hours later, two more merchant ships would arrive and rescue 31 others.

When the Australian navy boats HMAS Wollongong and HMAS Larakia arrived at 5.30 pm, they found people in orange lifejackets screaming for help, and blowing whistles to attract attention. As the sun set that evening, Australian navy personnel rescued Ahmed from of the water.

Ahmed: [translated] They treated us very well, I would say more than well. When we first saw them coming, some of our friends could see the Australian flag. We had heard good things about the Australian navy, and it was proved to be true when they took us onto their boat. They were very good with us.

Jess Hill: By the time 110 people were rescued, they had been struggling for 13 hours in rough seas. In all, 102 people went down with the boat.

Customs commissioned an internal report, known as the Buckpitt Report, to investigate the circumstances that led to the sinking. It found that AMSA could have been more proactive in helping the boat, especially as the vessel moved further away from Indonesia, and would probably have been beyond the reach of Indonesian assistance.

Detective Chief Inspector Dave Bryson, from West Australian Police's Major Crimes Unit, was assigned to investigate the sinking for the coronial inquest. He asked the Commonwealth to provide him with all the relevant documents they had.

Marco Tedeschi: When the West Australian Police asked for this information they meant everything—you know, secret, not secret, all of it—and for some reason which is not entirely clear, the Australian Federal Police indicated that they didn't want the information to be passed on to the West Australian Police.

Jess Hill: Half-an-hour before he was due to deliver his findings at the inquest, Detective Bryson discovered the Buckpitt Report had been concealed from him. Weeks of painstaking work, much of it duplicating material already in the Buckpitt Report, had been wasted. Angrily, he told the court he could no longer stand by his findings.

Last month, the West Australian Coroner Alastair Hope ruled the deaths to be an accident, but added that the asylum seekers had been justified in their fears, and that clearly if a search and rescue response had been initiated significantly earlier than it was, all of the deaths could have been avoided.

However, he also found that until the distress phase had been reached, it was not appropriate for commercial shipping, nor realistic for naval vessels, to go and check on the safety of the boat.

He was critical of the communications between Indonesia and Australia, labelling them 'inadequate'. Tony Kevin attended the inquest and was there when the coroner delivered his findings.

Tony Kevin: The Coroner was quite scathing of AMSA's lack of due diligence in checking that BASARNAS would respond adequately to the request to take on the responsibility for the rescue of SIEV 358. He pointed to the failure of AMSA to check properly as to what BASARNAS was doing to implement its rescue obligation, what equipment it had, what it did. He was quite scathing.

Jess Hill: The Coroner recommended that Australia work with Indonesia to improve their combined search and rescue responses.

Mal Larsen: Circumstances have changed in the sense that there's a lot closer communication. We have communication officers embedded in each other's organisation, and in fact we have been training BASARNAS officers to issue their own broadcast to shipping. Now the situation is that AMSA will routinely work with passing ships if a vessel is seeking assistance, or, if there are Australian assets available, we will send them to the scene.

Jess Hill: Counsel assisting the Coroner, Marco Tedeschi, says it will take a lot more than improving communications for Indonesia to be capable of properly responding to asylum boats in distress.

Marco Tedeschi: I think the lesson for Australia is that basically we have the greater capability to respond. Once these refugee boats are more than about 30 nautical miles off the coast of Indonesia, or even less than that, really my view is that we have to take the responsibility for it because we have the greater capabilities.

Jess Hill: The question that many people are asking is; if hundreds of Australian lives were at risk in a similar situation, would Australia rely on Indonesia to rescue them?

Background Briefing's coordinating producer is Linda McGinness, research by Anna Whitfeld, technical production by Mark Don, the executive producer is Chris Bullock, and I'm Jess Hill.